Transitional Care Clinics at RotaCare Pittsburg and Richmond Free Medical Clinics Background The goal of the Transitional Care Clinic (TCC) is to help improve the health of low income, uninsured patients with a single diagnosis of type II diabetes, hypertension, or asthma, or a combination of two of these conditions, who receive their care at the RotaCare Richmond and Pittsburg Free Medical Clinics in California. Both RotaCare clinics provide acute primary care as needed to patients, including access to diagnostic laboratory testing and imaging, and low-cost medications, as well as referrals to many follow-up procedures. In addition to these services, the TCC provides a coordinated, longitudinal program that includes multiple physician and nurse visits and examinations; a TCC patient care coordinator; free prescription medications and medical supplies, including blood pressure cuffs, glucose monitoring supplies, a scale; and lifestyle and health education counseling and workshops, such as cooking, mental health and stress reduction classes. Almost all TCC participants are undocumented, monolingual Spanish speaking Latinos, most have incomes that are less than 200% of the federal poverty level; most have less than 8th grade education (and many less than a fourth-grade education, and many cannot read or write in their native language); and all are uninsured. After the Covid pandemic, both clinics resumed in-person visits, and are continuing telehealth and telephone appointments. Training was provided to the patients on how to use their mobile devices to communicate with providers using the HIPAA compliant Zoom application. With the Telehealth system, medical providers are able to work from home or in the clinic. In many cases, we provided high-risk TCC patients with inexpensive tablets along with blood pressure monitors; pure oximetry monitors; blood glucose monitors and weight scales; and loan them the tablets which will need to be returned when no longer needed. If a TCC patient needs to be seen in person, the appropriate CDC Covid guidelines are followed. Both the Pittsburg and Richmond Clinics have been supplied with necessary PPE including N95 masks for the medical provider, surgical masks for patients, volunteers and staff; gloves in various sizes; shoe and hair covers, isolation gowns; full face shields; purple blue wipes; hand sanitizers; bleach; portable Plexiglas dividers and no-contact thermometers. We are conducting cooking classes, stress management, diabetes and hypertension classes on Zoom. While in the past group Zoom classes with TCC patients have been attempted, but found it difficult for TCC patients to attend Zoom classes, they have recently made considerable progress. At least half of the patients at both clinics have been able to participate in the TCC’ s coordinator’s weekly Zoom educational classes; and all patients at Pittsburg have joined Zoom telehealth provider visits, as have patients at Richmond. The mean age of the patients at Richmond is 10 years older than the mean age of Pittsburg patients, which is one possible reason for lower use of telehealth zoom visits among Richmond patients since older patients have more difficulty using the internet. Currently all of the patients at Pittsburg use their smart phones to attend educational classes and provider telehealth video visits. We have also partnered with the University of California at Berkeley School of Public Health to provide mental health classes as part of their Labor Occupational Health Program. Since March 2020, the Covid pandemic has hampered our ability to undertake all of the programs that we wanted to conduct as part of the TCC program, however the results are still very positive. Overall, TCC patient interviews, which were conducted in the fall of 2022, show very high patient satisfaction with the care they received from the TCC coordinator and the medical providers. Patients appreciated the caring and high quality, professional attention provided by the patient care coordinator, providers, and clinic staff, which became even more important during a highly stressful coronavirus pandemic. Consistent with our findings, the components patients most valued are the weekly phone calls from the patient care coordinator and the free prescription medications. Above all the patient care coordinator maintains the trust of our vulnerable TCC patient population. Patients recognized her phone number; and when she calls each week, they know she understands their situation and will be sure they get their provider appointments and receive their medicine. In addition, they valued the cooking, mental health and stress reduction classes that were practical and addressed their everyday needs. The important role that the family plays among Latinos was articulated in two ways in our interviews. First, participants expressed a strong appreciation for the group classes, such as the cooking, stress reduction, and walking group in which they could learn from each other and interact with members of their family and other members of the TCC. We expanded these group classes over the past year, both in person and on Zoom and plan to continue these classes moving forward. Another strong role for the family that is indirectly supported by the program is to help increase digital literacy among TCC participants. We received funding to provide all interested TCC patients with tablets so they can participate in Zoom classes given by the Patient Care Coordinator, as well as engage in digital Telehealth visits with their provider, rather than ordinary phone calls. These tablets are currently being used by a few patients in Richmond. We continue to build on interview comments suggesting that patients would welcome working with their kids who are tech savvy to enable them to take advantage of the telehealth opportunities that the RotaCare clinics are developing. The Richmond and Pittsburg clinics developed easy log on procedures for stress-free participation in Zoom calls, which TCC participants learn at the clinic and then practice at home with their teenage and adult children until they are comfortable using the tablet. The Transitional Care Clinics program, through the Foundation of the Rotary Club of Alamo, has received a three-year grant in the total amount of $150,000 ($50,000 per year for three years) from the John Muir Health System to be able to continue the TCC program. The John Muir Health System Grant will basically cover the salary of the TCC patient care coordinator and we are expected to raise additional funds to cover the approximately $20,000 per year shortfall. These funds are needed to cover the cost of providing patients with free prescription medications, laboratory tests, x-rays and other diagnostic tests, along with the purchase of glucometers, test strips, blood pressure devices, cooking classes and other program materials. The Foundation of the Rotary Club of Alamo has sufficient working capital from previous John Muir Health System grants to cover the budget shortfall for the 2022-2033 year and is requesting a 2023-2024 District Grant in the amount of $15,000 to cover years two and three of the grant. Answers to Questions posed by the grants review panel: Question 1. The shortfall cited will be made up from working capital carryover. We have the funds in hand now. Question 2. The $21,000 for medications was derived by looking back 18 months and calculating the average monthly expense and multiplying by 12.. it is thus based on actual experience from the program. Question 3. Corrected MOU was uploaded to the documents section.
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